This application is in response to an NIH NHLBI K01 Mentored Career Development Award to Promote Faculty Diversity in Biomedical Research (RFA-HL-12-030). Candidate: I am an exercise physiologist and 3rd year postdoctoral fellow within the Division of Cardiology at the University of Colorado Denver (UCD) Anschutz Medical Campus (AMC). I am currently funded through an NHLBI F32 individual postdoctoral fellowship based on my pilot project titled A community-based exercise program following endovascular therapy for patients with peripheral artery disease for which I also received a Colorado Clinical and Translational Sciences Institute (CCTSI) grant (project support). I have begun the process of receiving training in community-based participatory research (CBPR) methods to enhance my proposed research agenda of creating innovative exercise programs in community settings for patients with PAD. This was accomplished when I attended the 2010 Physical Activity and Public Health Practitioners (PAPH) course held in Park City, UT. I also participated in the Colorado Immersion Training in Community Engagement program, American Indian track. As a Tribal member of the Cherokee Nation, I am in an excellent position to continuing moving toward independent investigator status while also providing a unique perspective to clinical research based on my heritage and past training. Mentors/Environment: My mentor team is composed of national level research experts in PAD, CBPR methodology and built environment evaluation, cardiology as well as motivational interviewing. Dr. Judy Regensteiner is my primary mentor and has extensive experience in exercise training for patients with PAD and diabetes as well as in mentoring junior faculty. Dr. William Hiatt is a leader in clinical trials for PAD patiets and is the President of the Colorado Prevention Center which is a clinical trial design research organization. Dr. Deborah Main has expertise in community-based health research and has played a critical role in the CBPR methods of the proposal. Dr. Ivan Casserly is an academic cardiologist who is a leader in the field of peripheral vascular intervention. He will provide his expertise with regard to PAD patient care as well as aid in recruitment of PAD patients into our trial. Dr. Paul Cook is a consultant on this proposal for the motivational interviewing aspects of the design. He has a number of publications in using this technique in a variety of patient populations and will aid me in my continued training in motivational interviewing to improve PAD patients' adoption and adherence to exercise in community settings. Training: My plans are to continue my training in CBPR practices and motivational interviewing as well as in public health. This will be accomplished by participating in local and national level training opportunities for junior faculty in community-based and clinical outcomes research (e.g., CCTSI and PAPH programs). I anticipate completing a Master of Public Health degree during the proposed award period, specifically in the Community and Behavioral Health concentration. Additionally, I will be completing a Certificate in Public Health Sciences at the time of this application review. Research: Although supervised exercise programs for peripheral arterial disease (PAD) are highly effective, few people are able to successfully utilize these programs. Barriers that prevent patients from adopting and adhering to supervised exercise programs include lack of insurance reimbursement for walking exercise and poor proximity to hospitals and clinics as external barriers. Community-based exercise programs for PAD have to date met with inconsistent results possibly due to lack of training and follow-up. Thus, more consistent and directed programs need to be established for exercise training programs based in community settings that incorporate the strengths of supervised programs but also remove the barriers associated with exercise in the community. Our pilot project used novel training, monitoring and coaching (TMC) components in community settings that have been implemented successfully in supervised settings. We also evaluated the local walking environment for each PAD patient prior to community-based exercise. However, our previous pilot methods were designed from the researcher perspective and did not formally engage the actual PAD patients to gain their perspective on how to create effective interventions. Research programs that involve community members in developing the intervention to be used in the community setting may: 1) highlight additional barriers to walking using experiential knowledge of patients and 2) improve compliance by adjusting exercise prescription components that patients may have previously resisted completing. Thus, our project will use CBPR practices in the early design phase of the intervention to improve our piloted TMC intervention components in an effort to increase PAD patients' exercise performance. In addition, evidence supports exercise based motivational interviewing as an effective communication strategy for providing directed resolutions to problems while exercising and may improve self-efficacy of PAD patients. Thus, the primary aim of the proposed study is to determine the effect of a community-based exercise program with training, monitoring and coaching (TMC) components that are enhanced by CBPR practices and motivational interviewing (TMC+) to improve peak walking time (PWT) in PAD patients, which is the primary outcome of the study.
While supervised exercise is generally a first line therapy for patients with peripheral artery disease (PAD), it is considerably underutilized due to barriers such as inadequate insurance coverage and patient proximity to health care facilities. In contrast, exercise training programs based in the community setting have to date proven unsuccessful due to the reliance on patient self-monitoring as well as potential environmental barriers to exercise, lack of engaging patient?s and lack of adequate counseling techniques. Thus, it is important to establish the effectiveness of a community-based exercise therapy model incorporating detailed components (training, monitoring and coaching enhanced by community engagement and motivational interviewing) that, if successful, may serve as an alternative to supervised exercise therapy for patients with PAD.
